I listened to an interesting podcast on the ‘myths of manual therapy’ recently in which I was referred to as a ‘well-known Twitter personality’ who has been misleading therapists with my blogs on manual therapy. Well, of course, I strongly disagree with this… I actually consider myself more as an Instagram Guru than a Twitter personality these days.
But in all seriousness, I do have some points I want to raise about some of the claims made in this podcast with Chad Cook about a blog he wrote in German about the myths of manual therapy. First things first, despite disagreeing with Chad a lot around the topic of manual therapy, I agree with him a lot on other things and have no personal ‘beef’ with him, despite his digs, occasional character assassinations, and misrepresentations of my views on manual therapy that I see and hear from him .
However, putting all that to one side and for the sake of progress I would like to talk about four points Chad brings up in this short podcast. The first is that manual therapy adds value and improves patients’ experiences. Second is that self-efficacy is a deeply rooted and difficult trait to change. Third, there is no evidence that manual therapy causes dependence in patients. And finally, the use of manual therapy helps identify patients who have better outcomes.
Does manual therapy improve patients’ experiences?
I certainly agree with Chad when he says at the beginning of this podcast patient experiences are strongly linked with their outcomes. However, I strongly disagree when he says that patients experience more value with ‘hands-on’ and less value with ‘hands-off’ approaches.
This is because the experience and value a patient feels they get from any healthcare appointment is not just about what treatments they get, more about how they were treated.
You simply don’t magically and miraculously improve a patients experience of a healthcare appointment by touching them. You improve a patients experience of an appointment by listening, validating, empathising, explaining, reassuring, educating, and planning with them. If you don’t do any of the above well it really doesn’t matter if you touch them or not.
This persistent argument of improving patients experiences or meeting their expectation as justification for using manual therapy is, in my opinion, a rather lame and flimsy one. First because its been well documented that using patient satisfaction is a pretty ineffective way to measure a treatments efficacy or effectiveness (ref, ref, ref).
But also because despite all the criticisms around manual therapy no one has actually said don’t touch patients. In all my constant criticisms against manual therapy I have NEVER said anywhere at any time don’t touch patients. Just the opposite in fact.
I have written blogs, posted thoughts, opinions and many papers highlighting the importance and power of touch to patients to examine, reassure, facilitate, and encourage them.
There has never been any argument from me that using touch as a clinician is important and helps improve a patients experiences, usually by giving them the reassurance they have been fully examined and their issues are taken seriously. But this still doesn’t mean you have to use manual therapy treatments.
Is self-efficacy deeply rooted and difficult to change?
In the podcast, Chad also mentions that self-efficacy is a deeply rooted trait and that ‘it’s extremely difficult to change’. He also says that some (and I assume he is again referring to me here) clearly don’t understand it and haven’t read much about self-efficacy. Well, Chad, I’m no self-efficacy expert but I have read enough to think you are mistaken here.
The first issue is what does Chad mean by self-efficacy is deeply rooted. Self-efficacy of what? Self-efficacy on its own is not a thing as discussed by my mate Ben Cormack here. Self-efficacy is an individual’s judgement of their capability to do a specific task in a specific situation, therefore it is highly context dependant (ref).
For example, currently, I have very high ‘deadlift’ self-efficacy meaning I feel very capable to pick heavy things off the floor in a gym. However, this doesn’t mean I will have the same high levels of deadlift self-efficacy if I have low back pain.
Also, I currently have low ‘car maintenance’ self-efficacy meaning I don’t have a clue how to service my car these days with all its technology and gadgets. This means I also have very low ‘I’m broken down on the side of motorway’ self-efficacy. However, when I arrange some roadside assistance I very quickly change my low ‘I’m broken down on the side of the motorway’ self-efficacy to high.
So when Chad says self-efficacy is a deeply rooted trait and extremely hard to change I disagree, because it depends hugely on what the task and situation is.
When it comes to patient’s we usually refer to their pain self-efficacy. But again, what type of pain are we talking about? Back, shoulder, hip, little finger? Acute, chronic, mild, moderate, or severe? Because when it comes to pain self-efficacy different locations, types, and severity of pain can create different levels of self-efficacy in the same individual.
For example, a patient with chronic low back pain may have very low self-efficacy to bend forward and pick up a kettlebell during their physio session yet have much higher self-efficacy to bend forward and pick up their child up at home. What appears to be low and deeply rooted in one context may not be so much in another.
A final point I want to make in regard to self-efficacy is that it has been found to be a mediating factor in low back pain and disability (ref). However, we don’t actually have much evidence to show that improving self-efficacy is what helps reduce pain or disability, or that our interventions change it, which leads me nicely onto my third point.
Does manual therapy create dependence in patients?
In the podcast, Chad mentions that he has searched and scoured the evidence base in both a scoping and systematic way looking for any evidence of manual therapy creating dependence in patients and found none. From this, it appears, and I may be mistaken here, that he implies manual therapy doesn’t create dependence in patients.
This is a logical fallacy of mistaking an absence of evidence as evidence of absence, which is a saying often abused by quacks trying to justify woo. But putting aside the crystal healers and chakra cleansers Chad can NOT say that just because there is no evidence of manual therapy creating dependence in patients that it doesn’t occur or that can’t do this.
I must admit it was surprising and frustrating for me that my own efforts in searching the evidence base have also been unable to find any papers that show patients can become dependent on certain treatments such as manual therapy. This is because it goes against my 20+ years of front-line clinical experience of hearing and seeing 100’s if not 1000’s of patients demonstrating dependency on all forms of massage, manipulations, needles, injections, taping, and electrotherapy treatments.
But on further thought its not really that surprising, as to do this type of research I think would be extremely challenging and difficult to do well, and probably why no one has tried yet. The first issue is in trying to design a study looking for dependence on manual therapy or other passive treatments that is ethical, and as well controlled as possible to avoid the many possible confounding factors such as clinician and researcher equipoise and bias, but also trying to work out how to rate or judge dependence.
I don’t know about you but in my experience those who are most dependant on things tend to not be aware, recognise, or admit that they are dependent on things. Therefore, simply asking patients do you think you are dependent on X won’t work and asking clinicians the same will also have issues.
I do agree with points raised in the podcast that most patients are not stupid and don’t become dependent simply or easily. However, patients are often very trusting towards clinicians and I have seen far too many clever and intelligent people tell me that they go and see ‘their guy’ 5-6 times a year to get their pelvis put back in, or that muscle knot rubbed out for 5, 10 even 20+ years because they like, trust, and believe them to know it happens.
Will this ever be demonstrated in the evidence? I don’t know! Will this ever change? I don’t know! All I do know is I hear and see patients regularly receiving unnecessary treatments due to some false, misleading narrative given ignorantly or deliberately by some therapists providing them for payment.
Does manual therapy improve outcomes?
The final point I want to discuss is Chads points he raises around within and between session changes, that is patients who feel immediate improvements (within session) and those who feel delayed improvements (between session).
Chad discusses how there is evidence to show patients who have immediate within session changes have a small to moderate likelihood for good long-term outcomes, and those who have positive between session changes have very strong predictions of good outcomes in the long term. From this, and again I may have misinterpreted this, it appears Chad implies that manual therapy can therefore help improve patient’s outcomes.
However, I have some questions here. The first is couldn’t both these within and between session changes just be seen in patients with favourable natural histories improving regardless of the treatments they receive? I mean just because a patient gets some manual therapy and then displays some improvement next session doesn’t mean the manual therapy was the cause of that.
It could be those that have good within or between session improvements with manual therapy, or any other treatment, may just be those with low-risk factors, and conditions with favourable natural histories improving regardless.
Also, I maybe a little slow here but is it really that surprising that patients who show signs of improvement, tend to improve more than those who don’t show signs of improvement? Or am I missing something a bit deeper here with these studies?
So that’s my review of Chad’s recent podcast on his German blog in which I get a brief mention… I think. It’s a shame its not available in English as I would like to read it to make sure I am not misrepresenting Chads positions on his myth-busting of manual therapy because I know how annoying and frustrating that can be.
Now just in case, anyone is still unclear on what my position on manual therapy is I will lay it out once more. I believe that most manual therapy used in musculoskeletal therapy is overcomplicated, over-hyped, and overused. It is surrounded by a tonne of ego, elitism, and some absolute throbbers full of bluff and bravado who teach it, with ignorant, ill-informed, misleading and potentially harmful narratives about what it does and how it does it.
I think manual therapy is a low-value treatment because of its small, unreliable, short-lasting effects making it not worth the time, energy, and costs to provide it. This is not to say manual therapy doesn’t do anything for anyone, rather, that its best provided by those who can offer it at more reasonable costs to those who have a low risk of it not distracting them away from other more important interventions for their pain or disability.
As always thanks for reading